Metro Insurance Group

Person Requesting
Person Requesting this Quote

Personal Information

Name	First/Last
Address	Street City
	State Zip Code
Telephone	Home Work
E-mail	Fax

Underwriting Information
Are any aircraft owned, leased, chartered or furnished for regular use?	Aircraft	Yes No
Do any drivers have mental or physical impairments?	Mental or Physical Impairments	Yes No
Are any premises, vehicles, watercraft, aircraft used for business?	Used for Business	Yes No
Are any premises, vehicles, watercraft, aircraft owned, hired, leased or regularly used not covered by the primary policies?	Not Covered by Primary Policies	Yes No
Do you engage ina any type of farming operation?	Farming Operations	Yes No
Do you hold any non-remunerative positions?	Non-Remunerative Positions	Yes No
Do you employ any residence employees?	Residence Employees	Yes No
Any non-owned property exceeding $1,000 in value in your care, custody or control?	Non-Owned Property Over $1,000	Yes No
Any non-owned business or professional activities included in the primary policies?	Non-Owned Business Activities	Yes No
Does any primary policy have reduced limits of liability or eliminate coverage for specific exposures?	Reduced Limits	Yes No
Was any coverage declined, cancelled or non-renewed within the past 5 years?	Coverage Declined	Yes No
Any motorcycles, mopeds or all terrain vehicles owned?	Motorcycles Mopeds or All Terrain Vehicles	Yes No
Any other business activities conducted from your residence or premises?	Other Business Activities	Yes No
Please explain any YES answers from above


Driver 1 Information
First Name
Last Name
Gender	Male Female
Marital Status
Years Licensed
State Licensed
License Type
Driver 2 Information
First Name
Last Name
Gender	Male Female
Marital Status
Years Licensed
State Licensed
License Type
Driver 3 Information
First Name
Last Name
Gender	Male Female
Marital Status
Years Licensed
State Licensed
License Type
Driver 4 Information
First Name
Last Name
Gender	Male Female
Marital Status
Years Licensed
State Licensed
License Type


Violation Information
Last 3 years (minor violations) Last 5 years (major violations)
	Driver 1	Driver 2	Driver 3	Driver 4
Minor violations - speeding, turn, stop sign, red light, etc.
Accidents - non chargeable
Accidents - chargeable
Major violations - drunk driving, reckless, hit and run, etc.


Miscellaneous and Claims Information
What is the number of single family dwellings you own?	Single Family Dwellings Owned
What is the number of autos you own?	Autos Owned
What is the number of recreational vehicles you own?	RV Owned
What is the number of multi-unit buildings you own?	Multi-Unit Buildings Owned
What is the number of vacant property (land) you own?	Vacant Property Owned
What is the number of motorcycles you own?	Motorcycles Owned
Where there any losses or claims in the last 5 years?	Losses - Claims	Yes No
If yes, what is the date, amount paid and description of each loss or claim?

Coverage Information
What is the current insurance company?
How much are you paying now?	Amount Current Coverage
What is the liability limit requested?	Liability Limit

Questions or Comments.

Please Note: We cannot bind coverage from this email. Coverage is bound after you receive an email or telephone call from one of our agency staff members.